Quality Accreditation - The sustainable competitive advantage

Below is a whitepaper I had submitted for publication during a conference on Quality accreditation held in Pune.
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We live in exciting times in India. As an emerging market, India is at the centre of attraction of the world and everyone is talking about India as the land of opportunity. Indian Healthcare industry is one of the sectors of the economy which is leading this exuberance. All major consulting companies, be it KPMG or PwC, estimate double-digit growth figures for the healthcare industry for the next decade. An IBEF (India Brand Equity Foundation) report of November 2011 estimates healthcare industry size at US $280 Billion¹, bolstered by rising income levels, expanding middle class, an increasing appetite for premium services and conducive policy environment.

In all this hoopla, it is easy for anyone to miss the reality. The fact is that most investment in healthcare in India is by private sources and a lot of money in flowing into building new hospitals and adding more beds, given the low bed availability in our nation. According to World Health Statistics, India has 0.9 beds per 1000 population, way below the global average of 2.9². But most of this infrastructure is getting built in the metros and tier-I cities of the country leading to over-penetration in many areas. Most of this infrastructure is being built at a high capex. The mushrooming of hospitals in urban centres has led to an increasing competition among the various players. So on one hand, hospitals are grappling with higher costs, on the other hand they also need to fight tooth and nail with their peers to achieve moderate bed occupancy.

Indian healthcare also suffers from systemic flaws which haven’t been fixed due to misplaced priorities by both government and healthcare businesses. Even when the size of the industry has become US $50 Billion³, standardization of quality of care still remains a dream in our country. The pricing patterns even for common surgeries vary extremely in the country. Not many patients would agree that they could understand the processes or policies followed in the hospitals from which they received care. Most hospitals do not provide clarity on the services rendered by them and one can easily find examples of misrepresentation of services by hospitals in most of the Indian cities. Indian doctors have also been blamed for following unethical practices like prescribing over-medication and unnecessary diagnostic tests to pocket commissions from pharma companies and diagnostic centres respectively.

Visiting a hospital in India is a pain of its own kind. One can easily observe poor inter-departmental coordination and may even face eccentric rules and policies in a hospital. Most hospitals, for the sake of saving money, compromise on patient safety. While in the West, people are obsessed about preventing Healthcare-associated Infections (HAI) and there are elaborate studies on the risks to patients because of them, Indian hospitals are still sleeping over the issue. The biggest risk to patients arises from the inexperienced doctors and untrained medical professionals providing their services in our hospitals. Industry’s standard excuse has been the high rate of attrition and the huge demand pressures leading to compromises on quality of medical professionals. One can go on and on in identifying the problems that the industry faces. Finally, it is the trust of the patients that takes the beating because of these problems.

However, there has been a paradigm shift in how patients today consume healthcare services. In the internet age, patients are using social media to voice their opinions about the quality of care they receive at the hospitals. The present day patients question the treatment options offered to them by their doctors and many of them switch doctors easily if they are not satisfied. Gone are the days when patients trusted their doctors and hospitals with their eyes closed. The modern day patients demand healthcare providers to demonstrate quality in their services and deliver clinical excellence which is measurable and comparable.

Till a decade back, hospital accreditation was unheard of. National Accreditation Board for Hospitals and Healthcare Providers (NABH) was established in 2006 to bridge this huge gap between what the patients demanded and what the healthcare providers were offering. NABH standards for hospitals (1^st edition) began with 504 objective elements spread over 10 chapters and 100 standards and in its latest revision (3^rd edition) the NABH standards for hospitals have grown to 102 standards with 636 objective elements. Accreditation requires a healthcare provider to demonstrate its compliance to standards and after a stringent assessment process they are given the accredited status. This assumes significance in the light of the fact that till date only 138 hospitals⁴ in India have been able to achieve accreditation from NABH. According to one estimate, India has about 40,000 hospitals of small, medium and large scale⁵. Therefore, as per this estimate, not even 1 percent of hospitals in India have NABH accreditation.

In this scenario, accreditation presents a unique opportunity to healthcare providers. Quality accreditation can provide a sustainable competitive advantage to healthcare businesses if they build their strategy around creating NABH standards compliant infrastructure, policies and processes. A closer look at NABH standards indicate that the standards promote adherence to global best practices of healthcare delivery and there are detailed guidelines on measuring performance of hospitals on pre-defined quality indicators. Through a systematic approach, any healthcare business can achieve compliance to these standards. But it is easier said than done. Accreditation requires an organizational culture change which needs to be sustained for a longer period of time. A culture developed on the bedrock of quality care and patient safety will provide utmost quality assurance to patients and the community at large. Recent trends also indicate that patients have become more aware about accreditation and they are basing their choice of hospital on whether the hospital has any kind of accreditation or not.

Given the fact that only quality-focused hospitals will be able to achieve accreditation, it would ensure that those hospitals will always remain on top of the preference list of the patients. While the competing unaccredited hospitals may boast of great infrastructure, good doctors and affordable pricing, patients will not risk their lives with such institutions when an accredited facility is available in their city. It is a commonly known fact that in the matters of health, patients do not take their decisions based on the price of the treatment. Rather, they base their decisions on the treatment style of the doctor and assurance of better clinical outcomes. An accredited hospital would definitely enjoy an edge over its unaccredited peers. Since achieving accreditation is not an easy thing and an applicant may take couple of years to pass the NABH audit, this would ensure that an accredited facility stands out from the crowd.

In conclusion, it can be seen that there is a paradigm shift in healthcare industry in India. Accreditation bodies like NABH will play a vital role in ensuring delivery of quality care through the hospitals which are accredited by them. While there is an intense competition among hospitals, ones which have received accreditation will be able to provide greater assurance to patients about the quality of their care delivery system, something which their unaccredited peers cannot provide. Healthcare businesses need to have a strategy on leveraging accreditation to convey their superior care system to the patients. Since not even 1% of hospitals in India have received accreditation, this situation presents an opportunity for healthcare businesses to establish sustainable leadership position in their target markets by aligning their organizational culture and infrastructure to comply with quality accreditation standards.

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Sources:

1. Healthcare Report by IBEF, November 2011, URL: http://www.ibef.org/download/Healthcare50112.pdf, last accessed on August 8, 2012

2. The Times on India Online Article titled “India doesn't have even 1 hospital bed per 1,000 persons”, October 2011, URL: http://articles.timesofindia.indiatimes.com/2011-10-10/india/30262811_1_beds-tertiary-care-aiims, last accessed on August 8, 2012

3. The Economic Times Online Article titled “Indian Healthcare to double size to $100 bn by 2015”, January 2011, URL: http://articles.economictimes.indiatimes.com/2011-01-28/news/28428766_1_healthcare-sector-private-equity-indian-healthcare, last accessed on August 11, 2012

4. NABH, URL: www.nabh.co/main/hospitals/accredited.asp, last accessed on August 15, 2012

5. Views on Healthcare Quality Blog titled “eNABHle: Achieving NABH accreditation”, May 2012, URL:  http://ikureknowledge.blogspot.com/2012/05/enabhle-acheiving-nabh-accreditation.html, last accessed on August 15, 2012

HospiArch Bangalore: Voices from the Conference

The latest edition of AMEN’s series of conferences on Hospital Planning, Design and Architecture, aptly named as HospiArch, was organized on August 18^th and 19^th at API Bhavan, Bangalore. The event saw participation from over 100 delegates from different hospitals, architectural firms, consulting companies, engineering professionals and healthcare management students. The conference, supported by Hospaccx India Systems, is one of its kind event in India which attracts such a diverse set of audience. HospiArch is a 2-day conference which involves talks, panel discussion and Q&A sessions which are a rich source of knowledge to understand planning and design related issues for hospitals.

The Day 1 of the conference started with the Keynote address, delivered by Dr. (Wg Cdr) M.D. Marker, Medical Director - Bhagwan Mahaveer Jain Hospital Bangalore. In his speech, he addressed issues pertaining to architectural challenges involved in building a new hospital. He stressed the need for a hospital planner while designing a hospital and advocated a functional design approach.

His talk was followed by a presentation on “Planning & Designing a new hospital” by Dr. Alexander Kuruvilla, CEO - Medica Synergie Pvt. Ltd. Bangalore. He shared his vast experience in the field and the general steps for building a hospital such as feasibility study, market survey and project cost estimation & management. The highlights of his talk were his suggestions on having greenery, pipe music, aquarium & pleasant colours to keep the patients and relatives calm with in the hospital.

Dr. P. Satyanarayana, Retd. Professor of NIMS Hyderabad & Director of SVIMS Tirupati, took a session on “Factors that influence the bed utilization”. According to him, high cost of constructing physical infrastructure & facilities, high costs of running the hospital, high customer expectations and high cost of hospital expansion, modernization and modification bring sharp focus on bed utilization. He shared a few bed utilization indices, like Average Length of Stay (ALOS), Bed Occupancy Rate (BOR), Bed Turnover Interval (BTI) and Bed Turnover Ratio (BTR) as performance indicators. He advised to hospitals that while deciding to create more beds, they should consider factors like current availability of beds in an area, prevalent payment methods in the area (like cash or cashless), age of population (a higher life expectancy tends to raise general bed utilization), bed distribution (no. of ICU, PICU, ER and ward beds), availability of extramural medical services and medical customers & social patterns.

His presentation was followed by another talk by Mr. Radhakrishna, CEO - Narayana Hrudayalaya Hyderabad, on the topic of “Budgeting & financial planning for a new hospital project”. He gave elaborate prescription on planning of hospital project involving multiple steps. He suggested going for a market research, which would cover statistics on demographics, performance analysis of top 4-5 leading hospitals in the vicinity, identification of specialties and specialists, financial feasibility and project report. Next factor was the Land, its location and cost, legal formalities and statutory requirements for use of land for hospital purpose. When it comes to hospital building, he discussed factors such as cost of construction, various approvals, Floor Area ratio and determining built-up area per bed. Next thing he covered was medical equipment, its purchase costs and technology-relevance. He also touched various means of financing the project, such as equity or unsecured loans and debt/external funding. He finished his discussion by sharing some key ratios, such as debt-equity ratio, debt service coverage, bed occupancy rate, EBITDA margins and ALOS for measuring project performance.

Mr. Naresh Duble, DGM - Business Development at Armstrong World Industries (India) Pvt Ltd. Mumbai, presented on “Hospitals are for people - Design Solutions” and touched various facets of Acoustic comfort, green building and thermal comforts. Another presentation on “Designing a CSSD - Techniques and Trends” was given by Ms. Anuradha Desai, Manager - Getinge India Pvt. Ltd. Mumbai. She used elaborate layouts to explain her points. An interesting topic she discussed was about Super-CSSD which is out sourced CSSD for various hospital in countries like France, U.K, Singapore in which linen is sent for sterilization in super CSSD and dispatched back to hospital.

The last presentation of the first day was given by Dr. Marker on “Planning & designing lab & other diagnostics areas of the hospital”. His advice for planning and designing a lab was to focus on three areas: Strategic Planning, Structure Planning (scope of services & future expansion) and Operational Planning (functional lab Area). He also discussed about location and space requirements for a lab.

The Day 1 also witnessed a power-packed panel discussion on the topic of “Hospital Planning, Design & Architecture - Issues, Current Trends and Challenges”. The panel of 5 included Dr. P. Mohanakrishnan, CEO – Malabar Institute of Medical Sciences Calicut & Kottakal, Dr. Narendranath V., Chief Administrator – MS Ramaiah Hospitals, Mr. Tarun Katiyar, Principal Consultant – Hospaccx India Systems, Mr. Ramanand Prabhu, Director for Sourcing & Marketing – Global Healthcare Solutions and Dr. (Wg Cdr) M.D. Marker, Medical Director - Bhagwan Mahaveer Jain Hospital Bangalore. The panel discussion was moderated by Mr. Anuj Jindal, Senior Consultant – Hospaccx India Systems.

The discussion started with Mr. Jindal asking the hospital administrators on the panel to share their insights on common mistakes that they have come across that administrators have made while designing their hospitals. Dr. Mohan highlighted that administrators make a mistake when they do not create people-centric hospital designs. The structures are not built keeping in mind the needs of the employees and of the patients and their attenders.

Dr. Narendranath shared his experience with respect to the balance which needs to be maintained between academic and patient care requirements in the teaching hospital.

Dr. Marker gave an example from his professional experience wherein the statutory compliances and regulations were not completed understood before taking up the hospital project, thereby leading to considerable escalation of project cost and delay of the project by a couple of years. Mr. Tarun Katiyar took the example of small hospitals and their owners, wherein the doctors pump in their hard earned savings in building the hospital, but by the time the structure is built, either they lack enough funds to buy the medical equipments or they do not have enough working capital to run the hospital during the initial years of the hospital before it achieves profitability. This leads to the unfortunate situation in which the doctor either has to dump the hospital project or he starts looking out for buyers for his dream project.

Mr. Ramanand Prabhu highlighted the fact that hospital infrastructure and equipment is an important project cost and it has to be budgeted at the very beginning of the project and sourcing of same has to be identified well in advance. The panel also discussed innovative contemporary models of outsourcing certain departments to other specialized agencies who can co-invest in the projects, thus reducing the burden on the hospital administrators.

Day 2 of the conference witnessed 6 more speakers share their valuable experiences with the audience. The day began with Dr. Vinod Singh, Senior Consultant – Hospaccx India Systems, discussing the experience of their company in the field of hospital architecture. He stressed the fact that hospital architecture is very different from conventional architecture given the complex nature of hospital buildings and various loads requirements for the floors owing to heavy medical equipments and their power requirements.

This was followed by Prof. Dr. Usha Manjunath, Associate Professor – IHMR Bangalore, speaking on the topic of “Manpower planning for a new hospital”. She identified the importance of manpower planning as part of a new hospital project because of changing healthcare business paradigm, issues with availability of skilled manpower, vision of hospital promoters and the impact of policy issues on manpower requirements. Dr. Joy Bannerjee, Managing Director – Wiesermanner, discussed quality standards applicable to hospital planning, while Mr. Joseph Alexander, CTO - dWise Solutions & Services, discussed challenges in Hospital IT & Networking Design. Dr. Rajesh Kumar, Managing Director - Vijay Hospital Hosur, made a presentation on “Challenges in building hospitals in 2 tier towns” like the cost involved in the projects and the comparison of taking up a Brownfield project and a Greenfield project.

Lastly, Mr. Tarun Katiyar, Principal Consultant – Hospaccx India Systems, spoke on the topic “Re-planning & Re-designing an existing hospital”. His talk focused on the need for hospital renovation and how to go about it systematically. He gave elaborate examples of common mistakes hospital owners make while deciding to go for renovation of their buildings and suggested ways and means to avoid these mistakes.

In the end, HospiArch lived upto its expectation of being a source of great amount of learning for the participants and a good networking opportunity with the leaders in the hospital planning, designing and architecture services.

The next edition of HospiArch will be in Kochi next month. With the kind of conferences that happened earlier in Chennai, Hyderabad and Mumbai and now in Bangalore, HospiArch seems to be getting bigger and better. Let’s see what is in store for the audiences at Kochi in September. The last conference in the series in 2012 will be held in Delhi in December.

Accreditation Anonymous: Platform to collaborate for Quality professionals

Hi Healthcare Quality Community!

A friend of mine has taken this initiative to help us to collaborate and discuss issues pertaining to quality aspects in healthcare and accreditation of hospitals. The initiative is in the form of on Online Forum and it is called as Accreditation Anonymous and you can find the forum on this URL: www.accanon.com

The guiding thought behind this forum is to enable and support quality professionals to discuss matter pertaining to quality and accreditation in an environment where you can maintain your anonymity. The platform allows YOU to discuss sensitive matter pertaining to quality without getting named or without referring to a hospital.

This noble attempt, hopefully, will bring in healthcare professionals together to collaborate and collectively search for answers to their questions.

On behalf of my 'Anonymous' friend, I invite you to join this quality initiative.

In the support of STANDARDIZATION….

I think I should dedicate today to the concept of standardization. It is purely coincidence that I observed the need for standardization in two different aspects of healthcare today and I am writing on them on the same day itself. The previous mention was on having standardized patient satisfaction surveys across Indian hospitals (to copy the idea from HCAHPS).

I read this blog written by CQI CEO Simon Feary on how consistency can save lives. To read the blog, click here. His blog highlights hundreds of different types of bedside medical charts being used in UK hospitals leading to confusion among physicians and deficiencies in capturing important ‘vital signs’.

I think I second Simon’s demand for a consistent medical chart format that helps physicians to take appropriate decisions about patients’ health and safety. On the same thought, what are the opportunities for standardizing clinical documentation in our country?

The Handy Guide To Quality – Chartered Quality Institute

What is Quality? I keep bugging participants during my training sessions on NABH Quality Management System with this question and their answers vary a lot. Well, I found a great answer online today which I found to be the best.

This video, developed by CQI (Chartered Quality Institute), is a superb way to understand Quality in action. Incidentally, CQI also stands for Continuous Quality Improvement!

This 4-minutes video below can be a life-changing experience for some.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Curiosity has its own advantages. It helps you discover things you may otherwise miss. I have recently started following ASQ’s CEO Paul Borawski’s blog titled ‘A View from the Q’. Last month he had posted a blog that asked ASQ’s Influential Voices bloggers to share their views on ‘taking quality beyond products’. He had very nicely summarized everyone’s views in another blog. On the Service quality in healthcare, Nergis Soylemez had shared her opinion on her personal blog. Nergis comes with a background in quality in manufacturing industry and currently works with a hospital in Dallas. While reading her post, I came across something called as HCAHPS. The reason I was curious about this acronym was because it was a “government initiative to provide a standardized survey instrument to measure patients' perspective on hospital care”. Interesting, isn’t it?

So I went to HCAHPS’ website to find out what exactly this initiative is and what purpose does it serve. I was amazed at the fact that something as simple as a patient satisfaction survey has been standardized across a country, which has an opportunity to “publicly report patients' perspectives of care information that would enable valid comparisons to be made across all hospitals”. That is, to enable “apples to apples comparisons to support consumer choice”. WOW!!

The survey form is simple, nothing great about it. You can download it here. Or you can directly have a look at the survey form here.

As Nergis points out in her blog, the survey measures the performance of the hospital’s services on “several factors associated with patient satisfaction such as nurse communication, staff responsiveness, hospital environment and pain management”. In my experience, the patient experience/feedback forms that I have seen have been more elaborate on the services which were offered to patients for assessment. But what we can learn from HCAHPS initiative is that there is definitely a need for a standardization of feedback system so as to bring in comparability.

In an earlier blog also I had written about an attempt by NABH to bring in an objective system to rank the accredited hospitals on their performance on set objective performance indicators and NABH 3rd edition is a step towards that direction. On patient satisfaction also, we need a similar initiative in our country.

Meanwhile, readers can also enjoy this blog by Regina Holliday. Click on the photograph to visit her blog. She writes on Medical Advocacy.

Which regions in India are doing well in NABH Accreditation? A peek into the accreditation data.

During a recent discussion with a friend, a question came up – Which city/state/regions in India are doing well in terms of NABH accreditation? No one had a number at hand, except that 137 hospitals hold the accreditation and 2 of them having their status as “Accreditation kept in Abeyance” as we speak.

I got a chance to do what I love the most – Data analysis! Here’s the summary of data I found from NABH’s website, with the reference link: http://www.nabh.co/main/hospitals/accredited.asp (last accessed on July 20^th, 2012).

Here’s an alphabetical listing of city-wise number of accredited hospitals as of date:

City/State	No. of Accredited Hospitals
Ahmedabad	3
Amritsar	1
Bangalore	14
Bhavnagar	1
Calicut	2
Chennai	6
Cochin	1
Coimbatore	5
Ernakulum	1
Faridabad	4
Gandhinagar	2
Ghaziabad	3
Gurgaon	5
Hyderabad	10
Jaipur	4
Kalyan	1
Kerala	1
Kochi	1
Kolkata	3
Lucknow	1
Madurai	1
Manipal	1
Meerut	1
Mohali	2
Mumbai	7
Mysore	1
Nagpur	2
Namakkal	1
Nashik	1
New Delhi	29
Noida	4
Pune	2
Rajkot	1
Secunderabad	4
Sholingur	1
Surat	1
Thane	1
Thiruvananthapuram	1
Trichur	1
Udaipur	1
Vadodara	4
Visakhapatnam	1
Total	137

If we do a region-wise segmentation, the numbers would look like this:

Region	No. of Accredited Hospitals
East	3
North	50
South	53
West	31
Total	137

Clearly, NABH had the major impact closer to its base as Delhi has the maximum number of accredited hospitals, followed by my home-sweet-home Bangalore and Hyderabad finishes third.

Among themselves, the four metro cities of Delhi, Mumbai, Kolkata and Chennai account for 45 accredited hospitals, which is one-third the total number of accredited hospitals. Of course, Kolkata only contributes 3 hospitals to this sum, so I would say just 3 cities contribute 30% of the total accredited hospitals. Shouldn’t it be a cause of concern?

Region-wise, I got a shocker, with Eastern India only having 3 accredited hospitals, which is a paltry 2% of the total. I guess either NABH has not promoted itself well in the east of the country, or there aren’t good standard hospitals in that region. I hope the former is true. North and South share among themselves more than 100 accredited hospitals. But in the Northern region, except for Delhi, other states haven’t done as well as they should have done. Clearly, there is need to create awareness about NABH in those states and I would be happy if we could help.

In the South, there is a relatively even spread of accredited hospitals in various states, but Karnataka seems to have the edge. One possible reason could be the fact that Bangalore is the hub of a lot of activities that NABH conducts in the southern region (as per my observation).

NABH guidelines on OT air-conditioning: NABH HIC 2-J

The updated guidelines on OT design are available on NABH website and readers can refer to the following link to apprise themselves of the requirements.

http://qcin.org/nabh/documents/OperationTheatre/Operation-Theatre-Guidelines.pdf

Hope this is of use to the Quality professionals.

NABH Chapter 5 – Hospital Infection Control (HIC): Some references for making the Infection Control Manual

As part of NABH chapter HIC standard 2, there is a requirement for Infection Control Manual and the standard gives detailed guidelines on the components of the manual through its various objective elements. It also suggests CDC’s guidelines as good reference material for various infection control practices and areas.

Centre for Disease Control and Prevention (CDC) has specific guidelines for each kind of high-risk area to prevent Healthcare-associated Infections, or HAIs. Get CDC’s definition for HAIs here: http://www.cdc.gov/hai/

Get all the information about CDC guidelines for Infection control by visiting the following page: http://bit.ly/OaRTqZ 

More specifically, CSSD related guidelines, as suggested in NABH HIC 2F, are available in the CDC guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008 at the following link: http://bit.ly/OQD64S

If you have time, you can also watch this 2 minute video in which Dr. Denise Cardo, Director of the Division of Healthcare Quality Promotion, CDC, speaks about HAIs as a threat to Patient Safety and how we can respond to this challenge.

WHO ‘Safe Surgery Saves Lives’ Checklist: NABH COP 14

While dealing with care of patients who are undergoing surgical procedures, NABH recommends hospitals to refer to WHO ‘Safe Surgery Saves Lives’ Initiative. In this post, I bring to you a complete detail around the initiative and the checklist. This is also an important example that Dr. Atul Gawande quotes in his book – ‘The Checklist Manifesto: How to get things right’ and is one of my favourite books.

All the references are from the WHO’s website.

You can read an overview of the checklist on this page: http://bit.ly/OgsVIH

You can have a look at this 19 pointer checklist on the 20^th page of the pdf available on this link: http://bit.ly/NStgEM

I am sure you will have a lot of questions on what this checklist is all about and how to use it and is it applicable in your hospital. Don’t worry, WHO provides answers here: http://bit.ly/MtqbcY

And if you want to get a feel of how to do this checklist, watch the video below:

I’ve shown this video to 2 different audiences and both agreed that this checklist is short and crisp and can take care of a lot of elementary goof-ups that happen in their OTs and enhance patient safety. If you noticed, it doesn’t take more than 2 minutes each time you do the checklist. I think that’s time worth spent in protecting our patients.

Update on 30/08/2013
Based on a viewer comment, I felt there have to be other illustrations and videos for Safe Surgery Checklist which helps in better understanding of its implementation.

Below is a video from a hospital in Australia where a patient is undergoing Hip Replacement procedure. This one has the Pre-Incision (Time-Out) and Post-Procedure (Sign-Out) shoot only, but in a better detail.

This is another video from St. John of God Hospital in Australia. This one has two-part, the first one about how to do the Safe Surgery Checklist, and the second one about how not to do the checklist.